MassHealth 
Commonwealth of Massachusetts
EOHHS
www.mass.gov/masshealth

Personal-Care-Attendant Supplement

Please print clearly. Fill out all sections. If you need more space to finish any section on this form, please use a separate sheet of paper (include name and social security number), and attach it to this form.

Applicant/Member information

Last name
First name
MI
Telephone number
Social security number
Date of birth
Gender __ M   __ F
Street address
City
State
Zip

Information about your health problems

List and describe below all your medical and mental-health problems. Include anything that makes it hard for you to do daily living activities, like bathing, eating, toileting, dressing, etc., even if you are not getting treatment for the problem.
1.
2.
3.

Information about your daily living activities that you need physical (hands-on) help with

Please tell us in the chart below if you need hands-on help from another person to do the following daily living activities. If you check “yes” to any of the items below, tell us how often you need help.

Mobility (moving from bed to chair, walking, or using approved medical equipment)
Do you need hands-on help? __ yes   __ no
How many times a day do you need hands-on help?
How many days a week do you need hands-on help?

Taking medications
Do you need hands-on help? __ yes   __ no
How many times a day do you need hands-on help?
How many days a week do you need hands-on help?

Bathing (tub, bed bath, shower, or washing chair) or general grooming (like brushing teeth or combing hair)
Do you need hands-on help? __ yes   __ no
How many times a day do you need hands-on help?
How many days a week do you need hands-on help?

Dressing/Undressing
Do you need hands-on help? __ yes   __ no
How many times a day do you need hands-on help?
How many days a week do you need hands-on help?

Range-of-motion exercises (exercising joints by moving them)
Do you need hands-on help? __ yes   __ no
How many times a day do you need hands-on help?
How many days a week do you need hands-on help?

Eating
Do you need hands-on help? __ yes   __ no
How many times a day do you need hands-on help?
How many days a week do you need hands-on help?

Toileting (like getting on or off toilet, wiping yourself, getting clothes off and on, or changing diapers)
Do you need hands-on help? __ yes   __ no
How many times a day do you need hands-on help?
How many days a week do you need hands-on help?

Caregiver information

Please give us the name(s) and relationship to you of the person(s) who now helps you.

Caregiver name
Relationship to you (like relative, neighbor, personal-care attendant)

Caregiver name
Relationship to you (like relative, neighbor, personal-care attendant)

I certify, under penalty of perjury, that the information on this form is correct and complete to the best of my knowledge.

If you are acting on behalf of someone in filling out this form, a MassHealth Eligibility Representative Designation Form must also be filled out and sent back with this form. Your signature on this form as an eligibility representative certifies that the information on this form is correct and complete to the best of your knowledge.

Signature of applicant/member or eligibility representative
Print name
Date



PCA-SUPP (Rev. 10/12)



Document ends.